727341 research-article2017
PRF0010.1177/0267659117727341PerfusionLai et al.
Case report
Rescue intervention after three days of renal ischemia caused by acute complicated type B aortic dissection
Perfusion 1–4 © The Author(s) 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav https://doi.org/10.1177/0267659117727341 DOI: 10.1177/0267659117727341 journals.sagepub.com/home/prf
Chih-Hung Lai,1,2 Keng-Hao Chang,1,4 Szu-Ling Chang,2,3 Hui-Chih Lai,2,3 Wen-Lieng Lee1,2 and Tsun-Jui Liu1,2
Abstract Complicated type B dissection is associated with a high mortality rate due to malperfusion syndrome or progression of the dissection for which aggressive therapy with an endovascular or surgical intervention is recommended. Herein, we present a patient who received a successful percutaneous rescue intervention after three days of renal ischemia caused by a complicated type B dissection. This type of rescue of percutaneous intervention with branch vessel stenting appears to be useful in treating malperfusion syndrome caused by aortic dissection, even after a period of organ ischemia. Keywords type B aortic dissection; endovascular therapy; intravascular ultrasound; malperfusion syndrome
Introduction Aortic dissection is an uncommon, but serious, disease that is associated with a high mortality rate. The Stanford classification divides aortic dissections into type A, which involves the ascending aorta and requires surgical management and type B, which involves the descending aorta only and is treated medically.1 However, endovascular or surgical interventions are recommended for complicated type B dissections, defined as those involving malperfusion syndrome or signs of disease progression.2 Herein, we present a patient with a complicated type B dissection who received a successful rescue intervention after three days of renal ischemia.
Case Report A 52-year-old male presented to our hospital with acute onset chest tightness and cold sweats. Computed tomography of the aorta (CTA) showed a type B aortic dissection (TBAD) extending from the subclavian artery to the bilateral common iliac arteries and, also, into the celiac trunk. The blood supply to the superior mesenteric artery (SMA) and right renal artery mainly came from a false lumen. However, thrombosis of the false lumen had caused the true lumen in the proximal right renal artery to become severely compromised, resulting in poor blood flow to the right kidney and severely
decreased contrast enhancement of the right kidney parenchyma was also noted (Figure 1A and 1B). He was admitted for anti-pulse therapy, with nicardipine and labetalol to maintain his systolic blood pressure below 120 mmHg and pain control. The initial laboratory tests showed a creatinine level of 1.21 mg/dl. However, progressive deterioration of his renal function and decreased urine output developed. In addition, intermittent abdominal pain developed and became increasingly frequent. Three days later, his creatinine level increased to 1.84 mg/dl and urine output apparently decreased. However, he refused thoracic endovascular aortic repair (TEVAR) or a surgical intervention because of the possible complications. After discussion, he decided to receive rescue percutaneous transluminal 1Division
of Interventional Cardiology, Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan 2School of Medicine, National Yang-Ming University, Taipei, Taiwan 3Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan 4Department of Internal Medicine, Cheng Ching Hospital, Taichung, Taiwan Corresponding author: Tsun-Jui Liu, Division of Interventional Cardiology, Cardiovascular Center, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, Taiwan 40705, R.O.C. Email: [email protected]
2
Perfusion 00(0)
Figure 1. Angiography and angioplasty of the abdominal arteries. (A) Computed tomography of the abdominal aorta showed total occlusion of the proximal right renal artery (arrow). (B) Contrast enhancement in the right kidney was absent (arrow) compared with the left kidney. (C) Angiography of the superior mesenteric artery showed collaterals through the anterior and posterior inferior pancreaticoduodenal artery to the gastroduodenal artery (arrow). (D) Angiography of the celiac trunk showed ostial stenosis. (E) Intravascular ultrasound revealed a “curtain-like” dissection flap causing ostial stenosis of the celiac trunk. (F) After stenting, angiography of the celiac trunk showed good patency.
angioplasty (PTA) for the ischemic bowel symptoms and decreased renal function. PTA was performed via the right femoral artery, which was the true lumen, and confirmed by previous CTA. Angiography of the SMA showed good patency, but collaterals through the anterior and posterior inferior pancreaticoduodenal artery to the gastroduodenal artery (then to the celiac trunk system) (Figure 1C and Video 1, all videos can be found on-line with this article as supplementary material). A Sion Blue guidewire (Asahi Intecc, Nagoya, Aichi, Japan) was advanced to the distal SMA and intravascular ultrasound (IVUS) showed no dissection or impingement of the inner lumen. Due to apparent collaterals from the SMA to the celiac trunk, a celiac lesion was highly suspected. Angiography of the celiac trunk showed ostial stenosis (Figure 1D) and IVUS showed a “curtain-like” dissection flap and occlusion over the ostium of the celiac trunk (Figure 1E). Therefore, we placed a 0,035-inch guidewire into the distal splenic artery and deployed an Express LD 10x25-mm stent (Boston Scientific Corporation, Marlborough, MA, USA) at the proximal celiac trunk to the abdominal
aorta. Angiography showed good flow and IVUS confirmed the stent position and good expansion (Figure 1F). Right renal angiography was performed and showed total occlusion of the proximal right renal artery (Figure 2A and Video 2) by the false lumen. After wiring to the distal renal artery, IVUS was used to check the condition of the vessel, which showed that the long true lumen was compromised by thrombosis of the false lumen (Figure 2B and 2C, Video 3). We decided to place an Express SD 4x19-mm stent in the distal right renal artery, followed by an Express SD 5.0x19-mm stent (both Boston Scientific Corp.) in the proximal right renal artery to the ostium, which subsequently restored flow to the right kidney. After an IVUS examination (Figure 2D and 2E), the distal stent was post-dilated using a 5.0x15-mm non-compliance balloon up to 12 atmospheres and the proximal stent was dilated using the same balloon up to 16 atmospheres. Final angiography showed very good blood flow (Figure 2F, Video 4). After the procedure, the abdominal pain resolved and the urine output also improved. Three days after the intervention, the creatinine level decreased from 1.84 mg/dl to 1.59 mg/dl.
Lai et al.
3
Figure 2. Angiography and angioplasty of the right renal artery (RRA). (A) Initial angiography showed total occlusion of the proximal RRA. (B) Intravascular ultrasound (IVUS) showed that the true lumen of the middle RRA was severely compromised by thrombosis of the false lumen. (C) IVUS showed that the true lumen of the proximal RRA was severely compromised by hematoma of the false lumen. (D) IVUS showed an undersized distal RRA stent. (E) IVUS showed good expansion of the proximal RRA stent. (F) Final angiography of the RRA showed good blood flow.
Four days after the procedure, a renal function test with Tc-99m MAG3 showed that significant right renal function had been saved, with a total effective renal plasma flow of 330 ml/min, including 234 ml/min (71%) on the left side and 96 ml/min (29%) on the right side. One month later, the creatinine level improved to 1.45 mg/dl and the patient was also free from symptoms.
Discussion Complicated TBAD is defined by the presence of malperfusion syndrome, hemodynamic instability or signs of disease progression or rupture at presentation and during the hospital course. The in-hospital mortality rate for complicated TBAD is approximately 30–50% compared to less than 10% for uncomplicated TBAD.3,4 However, 12.4% of patients with initially uncomplicated TBAD subsequently require an intervention and/or die in the acute period within 15 days of starting medical therapy.5 More aggressive therapy with endovascular or surgical interventions is recommended for patients with complicated TBAD. Among these patients, the most common indication for an intervention is malperfusion
syndrome (36.0% renal ischemia followed by 28.0% mesenteric ischemia).5 These symptomatic features of ischemia may develop late and increased levels of biochemical markers, such as creatinine, liver enzymes and lactate, should be viewed with a high degree of suspicion. The recommended treatment for complicated TBAD, in addition to medical therapy, is TEVAR, followed by open surgery.2 TEVAR is performed by stenting of the aorta at the level of the proximal entry tear to reduce flow into the false lumen and restore enough true lumen flow. However, TEVAR may not work well if thrombosis of the false lumen causes static occlusion.5 In this situation, intravascular, image-guided, percutaneous interventions can help to reveal any static occlusion that could be overcome by branch vessel stenting. In our case, IVUS confirmed the static total occlusion of the true right renal artery. However, despite three days of renal ischemia, the renal function was still significantly saved by renal artery stenting. Therefore, even after a short period of renal ischemia, a rescue intervention with IVUS guidance and stenting is still worthwhile and effective to save residual renal function.
4 Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Daily PO, Trueblood HW, Stinson EB, et al. Management of acute aortic dissections. Ann Thorac Surg 1970; 10: 237–247. 2. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document
Perfusion 00(0) covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 35: 2873–2926. 3. Nauta FJ, Trimarchi S, Kamman AV, et al. Update in the management of type B aortic dissection. Vasc Med 2016; 21: 251–263. 4. Patel AY, Eagle KA, Vaishnava P. Acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection. Ann Cardiothorac Surg 2014; 3: 368–374. 5. Scott AJ, Bicknell CD. Contemporary management of acute type B dissection. Euro J Vasc Endovasc Surg 2016; 51 :452–459.
PRF0010.1177/0267659117727341PerfusionLai et al.
Case report
Rescue intervention after three days of renal ischemia caused by acute complicated type B aortic dissection
Perfusion 1–4 © The Author(s) 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav https://doi.org/10.1177/0267659117727341 DOI: 10.1177/0267659117727341 journals.sagepub.com/home/prf
Chih-Hung Lai,1,2 Keng-Hao Chang,1,4 Szu-Ling Chang,2,3 Hui-Chih Lai,2,3 Wen-Lieng Lee1,2 and Tsun-Jui Liu1,2
Abstract Complicated type B dissection is associated with a high mortality rate due to malperfusion syndrome or progression of the dissection for which aggressive therapy with an endovascular or surgical intervention is recommended. Herein, we present a patient who received a successful percutaneous rescue intervention after three days of renal ischemia caused by a complicated type B dissection. This type of rescue of percutaneous intervention with branch vessel stenting appears to be useful in treating malperfusion syndrome caused by aortic dissection, even after a period of organ ischemia. Keywords type B aortic dissection; endovascular therapy; intravascular ultrasound; malperfusion syndrome
Introduction Aortic dissection is an uncommon, but serious, disease that is associated with a high mortality rate. The Stanford classification divides aortic dissections into type A, which involves the ascending aorta and requires surgical management and type B, which involves the descending aorta only and is treated medically.1 However, endovascular or surgical interventions are recommended for complicated type B dissections, defined as those involving malperfusion syndrome or signs of disease progression.2 Herein, we present a patient with a complicated type B dissection who received a successful rescue intervention after three days of renal ischemia.
Case Report A 52-year-old male presented to our hospital with acute onset chest tightness and cold sweats. Computed tomography of the aorta (CTA) showed a type B aortic dissection (TBAD) extending from the subclavian artery to the bilateral common iliac arteries and, also, into the celiac trunk. The blood supply to the superior mesenteric artery (SMA) and right renal artery mainly came from a false lumen. However, thrombosis of the false lumen had caused the true lumen in the proximal right renal artery to become severely compromised, resulting in poor blood flow to the right kidney and severely
decreased contrast enhancement of the right kidney parenchyma was also noted (Figure 1A and 1B). He was admitted for anti-pulse therapy, with nicardipine and labetalol to maintain his systolic blood pressure below 120 mmHg and pain control. The initial laboratory tests showed a creatinine level of 1.21 mg/dl. However, progressive deterioration of his renal function and decreased urine output developed. In addition, intermittent abdominal pain developed and became increasingly frequent. Three days later, his creatinine level increased to 1.84 mg/dl and urine output apparently decreased. However, he refused thoracic endovascular aortic repair (TEVAR) or a surgical intervention because of the possible complications. After discussion, he decided to receive rescue percutaneous transluminal 1Division
of Interventional Cardiology, Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan 2School of Medicine, National Yang-Ming University, Taipei, Taiwan 3Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan 4Department of Internal Medicine, Cheng Ching Hospital, Taichung, Taiwan Corresponding author: Tsun-Jui Liu, Division of Interventional Cardiology, Cardiovascular Center, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, Taiwan 40705, R.O.C. Email: [email protected]
2
Perfusion 00(0)
Figure 1. Angiography and angioplasty of the abdominal arteries. (A) Computed tomography of the abdominal aorta showed total occlusion of the proximal right renal artery (arrow). (B) Contrast enhancement in the right kidney was absent (arrow) compared with the left kidney. (C) Angiography of the superior mesenteric artery showed collaterals through the anterior and posterior inferior pancreaticoduodenal artery to the gastroduodenal artery (arrow). (D) Angiography of the celiac trunk showed ostial stenosis. (E) Intravascular ultrasound revealed a “curtain-like” dissection flap causing ostial stenosis of the celiac trunk. (F) After stenting, angiography of the celiac trunk showed good patency.
angioplasty (PTA) for the ischemic bowel symptoms and decreased renal function. PTA was performed via the right femoral artery, which was the true lumen, and confirmed by previous CTA. Angiography of the SMA showed good patency, but collaterals through the anterior and posterior inferior pancreaticoduodenal artery to the gastroduodenal artery (then to the celiac trunk system) (Figure 1C and Video 1, all videos can be found on-line with this article as supplementary material). A Sion Blue guidewire (Asahi Intecc, Nagoya, Aichi, Japan) was advanced to the distal SMA and intravascular ultrasound (IVUS) showed no dissection or impingement of the inner lumen. Due to apparent collaterals from the SMA to the celiac trunk, a celiac lesion was highly suspected. Angiography of the celiac trunk showed ostial stenosis (Figure 1D) and IVUS showed a “curtain-like” dissection flap and occlusion over the ostium of the celiac trunk (Figure 1E). Therefore, we placed a 0,035-inch guidewire into the distal splenic artery and deployed an Express LD 10x25-mm stent (Boston Scientific Corporation, Marlborough, MA, USA) at the proximal celiac trunk to the abdominal
aorta. Angiography showed good flow and IVUS confirmed the stent position and good expansion (Figure 1F). Right renal angiography was performed and showed total occlusion of the proximal right renal artery (Figure 2A and Video 2) by the false lumen. After wiring to the distal renal artery, IVUS was used to check the condition of the vessel, which showed that the long true lumen was compromised by thrombosis of the false lumen (Figure 2B and 2C, Video 3). We decided to place an Express SD 4x19-mm stent in the distal right renal artery, followed by an Express SD 5.0x19-mm stent (both Boston Scientific Corp.) in the proximal right renal artery to the ostium, which subsequently restored flow to the right kidney. After an IVUS examination (Figure 2D and 2E), the distal stent was post-dilated using a 5.0x15-mm non-compliance balloon up to 12 atmospheres and the proximal stent was dilated using the same balloon up to 16 atmospheres. Final angiography showed very good blood flow (Figure 2F, Video 4). After the procedure, the abdominal pain resolved and the urine output also improved. Three days after the intervention, the creatinine level decreased from 1.84 mg/dl to 1.59 mg/dl.
Lai et al.
3
Figure 2. Angiography and angioplasty of the right renal artery (RRA). (A) Initial angiography showed total occlusion of the proximal RRA. (B) Intravascular ultrasound (IVUS) showed that the true lumen of the middle RRA was severely compromised by thrombosis of the false lumen. (C) IVUS showed that the true lumen of the proximal RRA was severely compromised by hematoma of the false lumen. (D) IVUS showed an undersized distal RRA stent. (E) IVUS showed good expansion of the proximal RRA stent. (F) Final angiography of the RRA showed good blood flow.
Four days after the procedure, a renal function test with Tc-99m MAG3 showed that significant right renal function had been saved, with a total effective renal plasma flow of 330 ml/min, including 234 ml/min (71%) on the left side and 96 ml/min (29%) on the right side. One month later, the creatinine level improved to 1.45 mg/dl and the patient was also free from symptoms.
Discussion Complicated TBAD is defined by the presence of malperfusion syndrome, hemodynamic instability or signs of disease progression or rupture at presentation and during the hospital course. The in-hospital mortality rate for complicated TBAD is approximately 30–50% compared to less than 10% for uncomplicated TBAD.3,4 However, 12.4% of patients with initially uncomplicated TBAD subsequently require an intervention and/or die in the acute period within 15 days of starting medical therapy.5 More aggressive therapy with endovascular or surgical interventions is recommended for patients with complicated TBAD. Among these patients, the most common indication for an intervention is malperfusion
syndrome (36.0% renal ischemia followed by 28.0% mesenteric ischemia).5 These symptomatic features of ischemia may develop late and increased levels of biochemical markers, such as creatinine, liver enzymes and lactate, should be viewed with a high degree of suspicion. The recommended treatment for complicated TBAD, in addition to medical therapy, is TEVAR, followed by open surgery.2 TEVAR is performed by stenting of the aorta at the level of the proximal entry tear to reduce flow into the false lumen and restore enough true lumen flow. However, TEVAR may not work well if thrombosis of the false lumen causes static occlusion.5 In this situation, intravascular, image-guided, percutaneous interventions can help to reveal any static occlusion that could be overcome by branch vessel stenting. In our case, IVUS confirmed the static total occlusion of the true right renal artery. However, despite three days of renal ischemia, the renal function was still significantly saved by renal artery stenting. Therefore, even after a short period of renal ischemia, a rescue intervention with IVUS guidance and stenting is still worthwhile and effective to save residual renal function.
4 Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
References 1. Daily PO, Trueblood HW, Stinson EB, et al. Management of acute aortic dissections. Ann Thorac Surg 1970; 10: 237–247. 2. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: document
Perfusion 00(0) covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 35: 2873–2926. 3. Nauta FJ, Trimarchi S, Kamman AV, et al. Update in the management of type B aortic dissection. Vasc Med 2016; 21: 251–263. 4. Patel AY, Eagle KA, Vaishnava P. Acute type B aortic dissection: insights from the International Registry of Acute Aortic Dissection. Ann Cardiothorac Surg 2014; 3: 368–374. 5. Scott AJ, Bicknell CD. Contemporary management of acute type B dissection. Euro J Vasc Endovasc Surg 2016; 51 :452–459.
